customer application

INFORMATION FOR THE ADDRESS YOU ARE DISCONNECTING

Date of Disconnect:

Phone#:

Customer Name:

Last 4 digits of Social Security #

Disconnect Address

Forwarding Mailing Address

INFORMATION FOR THE ADDRESS YOU ARE TRANSFERRING

Date of Connect:

New Utility Address

Rent

Own

Mailing Address

City:

State

Zip Code

Home Phone #

Cell #

Cell Phone/Text #

Choose preferred method (s) of contact: Email Home Phone Cell ___Cell Phone/Text

ANY BALANCES OWED ON YOUR UTILITY ACCOUNT MUST BE PAID PRIOR TO YOUR SERVICES BEING TRANSFERRED. YOU MAY CALL 407-323-1714 FOR YOUR CURRENT ACCOUNT BALANCE. By signing below, I acknowledge that I am responsible for any unpaid balance. I also acknowledge that any past due unpaid balance will be transferred to any existing or new Midway Canaan Community Water Association utility account.

Signature

Date

Disconnect/Transfer Form

INFORMATION FOR THE ADDRESS YOU ARE DISCONNECTING

INFORMATION FOR THE ADDRESS YOU ARE TRANSFERRING

Choose preferred method (s) of contact: __Email __Home Phone __Cell _____Cell Phone/Text

Choose preferred method (s) of contact: Email Home Phone Cell ___Cell Phone/Text